What is the management plan for ischemic Cerebrovascular Accident (CVA)?

Management of Ischemic Cerebrovascular Accident (CVA)

Administer IV alteplase (0.9 mg/kg, maximum 90 mg) within 3 hours of symptom onset to eligible patients, with 10% as bolus over 1 minute and 90% infused over 60 minutes, targeting door-to-needle time under 60 minutes, followed by endovascular thrombectomy for large vessel occlusions within 6-24 hours based on imaging selection. 1

Immediate Assessment and Stabilization

Airway and Oxygenation

• Provide airway support and ventilatory assistance for patients with decreased consciousness or bulbar dysfunction to prevent aspiration 2
• Maintain oxygen saturation ≥94% with supplemental oxygen if needed 2
• Assess swallowing before allowing any oral intake, as aspiration pneumonia is a major cause of post-stroke mortality 3, 1

Hemodynamic Stabilization

• Correct hypovolemia with normal saline and treat cardiac arrhythmias 2
• Perform ECG monitoring for at least 24 hours to detect atrial fibrillation, which is a major embolic source 4

Blood Pressure Management

Critical distinction: Blood pressure targets differ dramatically before versus after thrombolysis.

Before alteplase administration:

• Blood pressure must be reduced to <185/110 mmHg before initiating thrombolysis 1
• Use labetalol, nicardipine, or clevidipine to lower blood pressure if needed 1

After alteplase administration:

• Maintain blood pressure ≤180/105 mmHg for at least 24 hours 1
• Monitor every 15 minutes during infusion and for 2 hours after, then every 30 minutes for 6 hours, then hourly until 24 hours 1

For patients NOT receiving thrombolysis:

• Avoid lowering blood pressure unless systolic BP >220 mmHg or diastolic BP >120 mmHg, as aggressive reduction worsens ischemic injury 2
• If reduction is necessary, lower cautiously by approximately 15% during the first 24 hours 2

Reperfusion Therapy

IV Alteplase Eligibility

Inclusion criteria:

• Clearly defined symptom onset within 3 hours (use last known well time, not when symptoms were discovered) 1
• Measurable neurologic deficit on NIHSS 1
• Age ≥18 years 1
• Non-contrast CT showing no hemorrhage 1

Critical exclusion criteria:

• Blood pressure >185/110 mmHg despite treatment 1
• Platelet count <100,000 1
• INR >1.6 or PT >15 seconds 1
• Glucose <50 or >400 mg/dL 1
• Prior stroke or serious head injury within 3 months 1
• Major surgery within 14 days 1
• History of intracranial hemorrhage 1
• Rapidly improving or minor symptoms 1

Alteplase Dosing Protocol

• Total dose: 0.9 mg/kg (maximum 90 mg) 1
• Give 10% as IV bolus over 1 minute 1
• Infuse remaining 90% over 60 minutes 1

Endovascular Thrombectomy

Indications:

• Proximal anterior circulation large vessel occlusion (ICA, M1, proximal M2) 1
• Standard window: within 6 hours of symptom onset 1
• Extended window: up to 24 hours in selected patients with favorable CT perfusion or MRI diffusion/perfusion mismatch 1

Preferred devices:

• Stent retrievers (Solitaire FR, Trevo) are generally preferred over coil retrievers (Merci) 3
• Combined stent-retriever and aspiration technique (BADDASS approach) is optimal 1

Critical transport decision:

• Transport directly to comprehensive stroke centers capable of endovascular therapy when large vessel occlusion is suspected ("mothership" approach preferred over "drip-and-ship" when feasible) 1
• Patients eligible for IV rtPA should receive it even if intra-arterial treatments are being considered 3

Post-Thrombolysis Monitoring

Neurological Surveillance

• Monitor every 15 minutes during and for 2 hours after infusion 1
• Then every 30 minutes for the next 6 hours 1
• Then hourly until 24 hours 1

Immediately stop infusion and obtain emergency head CT if:

• Severe headache develops 1
• Acute hypertension occurs 1
• Nausea or vomiting appears 1
• Any neurological worsening 1

Symptomatic Intracranial Hemorrhage Management

• Stop alteplase infusion immediately 1
• Obtain emergent non-contrast head CT 1
• Check CBC, PT/INR, aPTT, fibrinogen, and type and cross-match 1
• Administer cryoprecipitate and tranexamic acid or ε-aminocaproic acid 1
• Consult hematology and neurosurgery 1

Antiplatelet Therapy

• Administer oral aspirin 160-325 mg within 24-48 hours after stroke onset for patients not receiving thrombolysis 2, 1
• Delay aspirin until >24 hours after thrombolysis for patients who received IV alteplase, and only after follow-up imaging rules out hemorrhage 2, 1
• Research confirms aspirin effectiveness in daily practice with acceptable safety profile 5

Anticoagulation

Avoid routine urgent anticoagulation for acute ischemic stroke, as it increases hemorrhagic risk without proven benefit for preventing early recurrent stroke. 2

Exception for DVT prophylaxis:

• Use subcutaneous anticoagulants (unfractionated heparin or low molecular weight heparin) for immobilized patients to prevent deep vein thrombosis 3, 4
• No significant difference in efficacy or safety between unfractionated heparin and low molecular weight heparins 3
• Alternative: intermittent external compression devices for patients who cannot receive anticoagulants 3, 2

Specialized Stroke Unit Care

All stroke patients should be admitted to a geographically defined stroke unit with specialized staff within 24 hours of arrival. 3, 1

• Stroke unit care reduces mortality and morbidity with benefits comparable to IV rtPA 3
• Standardized stroke orders and integrated pathways improve adherence to best practices 3
• Dedicated stroke nursing care is essential and cannot be overstated 3

Management of Acute Neurological Complications

Cerebral Edema and Increased Intracranial Pressure

Do NOT use corticosteroids for cerebral edema management following ischemic stroke. 2, 1

• Monitor for cerebral edema, which typically peaks 3-5 days after stroke but can occur earlier with large infarctions 4
• Use osmotherapy and hyperventilation for patients deteriorating due to increased intracranial pressure or herniation syndromes 2, 1

Surgical interventions:

• Decompressive hemicraniectomy should be performed urgently for malignant MCA infarction before significant GCS decline or pupillary changes, ideally within 48 hours of onset 1
• Surgical decompression may be life-saving for large cerebellar infarctions with brainstem compression 1

Seizure Management

• Treat new-onset seizures with short-acting medications 1
• Do NOT use prophylactic anticonvulsants 1

Physiological Parameter Management

Temperature Control

• Monitor temperature every 4 hours for the first 48 hours 1
• Treat fever >37.5°C with antipyretics 1
• Identify and treat sources of hyperthermia 1
• Avoid hypothermia except in clinical trial contexts 1

Glucose Management

• Monitor blood glucose regularly 1
• Treat hyperglycemia to maintain 140-180 mg/dL 1
• Avoid hypoglycemia with close monitoring 1

Nutrition and Swallowing

• Perform water swallow test at bedside as screening 3
• Videofluoroscopic modified barium swallow examination if indicated 3
• For patients who cannot take food orally, use nasogastric, nasoduodenal, or PEG feedings to maintain hydration and nutrition 3
• Consider percutaneous endoscopic gastric tube if prolonged need is anticipated 3

Prevention of Subacute Complications

Deep Vein Thrombosis Prophylaxis

• Implement early mobilization when medically stable 4, 1
• Use subcutaneous anticoagulants for immobilized patients 3, 4
• Alternative: intermittent external compression stockings for patients who cannot receive anticoagulants 3, 2
• Aspirin is less effective than anticoagulants but can be used if anticoagulants are contraindicated 3

Infection Prevention

• Administer antibiotics to treat infectious complications promptly 3
• Pneumonia is a major cause of post-stroke death, especially in immobile patients 3
• Avoid indwelling bladder catheters when possible due to infection risk; use intermittent catheterization instead 3

Early Rehabilitation

• Begin rehabilitation assessment within 48 hours of admission 1
• Start frequent, brief out-of-bed activity within 24 hours if no contraindications 1
• Screen swallowing, nutrition, and hydration status on the day of admission 1

Secondary Prevention

Lipid Management

• Initiate high-intensity statin therapy regardless of baseline cholesterol levels 2, 4
• Research shows total cholesterol elevation in 52% of ICVA patients 6

Carotid Evaluation

• Evaluate for carotid stenosis with duplex ultrasound or CT angiography 2
• Perform urgent carotid revascularization within 2 weeks if ≥70% symptomatic stenosis is identified 2

Atrial Fibrillation Management

• Atrial fibrillation is the major risk factor for ICVA (OR 1.96 in men, 3.54 in women) 7
• AF patients on anticoagulant therapy have significantly reduced risk of ICVA (OR 0.39) 7
• Consider anticoagulation after ruling out hemorrhagic transformation 4

Blood Pressure Management (Long-term)

• Start antihypertensive therapy after the acute phase (typically 24-48 hours post-stroke) 4
• Antihypertensive drug discontinuation increases ICVA risk, especially in women (OR 2.53) 7

Critical Interventions to AVOID

Do NOT use the following outside clinical trials:

• Glycoprotein IIb/IIIa inhibitors 2
• Volume expansion strategies 2
• Vasodilators 2
• Induced hypertension strategies 2
• Hyperbaric oxygen therapy (except for air embolization) 2
• Neuroprotective agents (lack demonstrated efficacy) 2

Common Pitfalls

Every 30-minute delay in recanalization decreases good functional outcome by 8-14%. 1

• Failure to obtain follow-up imaging at 24 hours before starting antiplatelets or anticoagulants increases hemorrhage risk 1
• Inadequate blood pressure control before thrombolysis significantly increases symptomatic intracranial hemorrhage risk 1
• Using "time symptoms discovered" instead of "last known well time" may inappropriately exclude eligible patients from thrombolysis 1
• Aggressive blood pressure reduction in non-thrombolysis patients can worsen ischemic injury 2